Practical Tips on Breastfeeding Dr Yvonne Ng Peng Mei Consultant Department of Neonatology National University Hospital
[email protected] 15 May 2010
Outline 1. 2. 3. 4. 5. 6.
The optimum duration of breastfeeding Breastfeeding pattern in first week of life Helping a mother to increase her milk supply Treatment of mastitis and sore nipples Safe medications in breastfeeding Referral of mothers with breastfeeding concerns
What is the optimum duration of breastfeeding?
When discussing feeding options with parents of healthy full-term infants, what do you recommend for the first 4 months of life? A. Breastfeeding exclusively B. Breastfeeding with formula supplementation C. Make no recommendation/support mother’s choice
Guidelines on Infant Nutrition To achieve optimal infant nutrition for normal growth and development
WHO/UNICEF 2002: Exclusive breastfeeding for 6 months, start adequate complementary feeding from 6 months with continued breastfeeding up to 2 years and beyond ESPGHAN 2008 Exclusive breastfeeding for about 6 months is a desirable goal. Complementary foods introduced not before 17 weeks, no later than 26 weeks (“4 months – 6 months”)
Breastfeeding is an effective way to prevent allergy • Exclusive breastfeeding for 4 – 6 months is the most effective measure for preventing allergic diseases (atopic dermatitis, cow milk allergy, wheezing in early childhood) in high risk patients
Other benefits of breastfeeding • To child – Protect from acute illness (AGE, RTI), bacterial meningitis, bacteremia, NEC & late onset sepsis in preterm infants – Less risk of obesity, long term health problems (cardiovascular health) – Reduce risk of SIDS – Higher cognitive functioning
• To mother – Reduce postpartum haemorrhage – Child spacing – Reduce type 2 diabetes – Reduce ovarian cancer – Reduce breast cancer – Decrease risk of osteoporosis
• To society – Cost effective – Environmentally friendly
What is “usual” pattern of breastfeeding in first week of life Understand physiology of breastfeeding
Good attachment Effective Suckling • Slow, deep sucks and swallowing sounds
• Chin touching breast • Lower lip turned outwards • Areola: more visible above than below the mouth • Mouth wide open
• Baby feeds calmly and seems satisfied • Mother feels no pain
Two hormones
From Infant and young child feeding. Model Chapter for textbooks for medical students and allied health professionals. World Health Organization 2009
Breastfeeding pattern • To ensure adequate milk production for baby’s growth, baby needs to be able to feed as often and as long as he wants to, day and night • “Demand feeding” or “baby-led feeding” and based on early feeding cues • Baby feeds 8 – 12 x/day in the first week of life
Fully Breastfed Babies in First Week Day of life Wet diapers in 24 hour Stools in 24 hours First 24 hours 1 1 meconium Day 2
2
2 meconium
Day 3
3
Stool colour change
Day 4
4, light yellow
Transitional stools
Day 5
5, colourless
3 - 4 yellow stools
Day 6+
6+,colourless
4+ stools, freq and colour varies
Weight pattern Weight loss less than 7% of birth weight on day 3 – 4 Regains birth weight between day 10 –14
Scenario • Full term baby boy, 3.5kg, normal vaginal delivery • Baby rooms-in with mother and does on-demand feeding • On day 4 of life, baby has mild jaundice, lost 9% from his birth weight. Passed 2 wet diapers and 2 meconium stools last 24 hours. Mother reports that her milk has just come in, no breast or nipple pain. • You remember that a 7% weight loss and persistence of meconium may mean “inadequate breastfeeding” Do you recommend formula supplementation? Answer is NO: Remember to assess both mother and baby. Do not depend on 1 or 2 factors. Mother can continue breastfeeding on demand. If discharged today, arrange an appointment in 2 days to check baby is putting on weight and mother is breastfeeding well.
Reference: Beststart Canada
When is “milk” produced? Delayed lactogenesis or normal variant?
Be aware of baby’s feeding styles
Scenario • You see mother with baby on day 7, who is formula fed. She attempts breastfeeding twice a day. She asks how to increase her milk supply. • History – First child, full term vaginal delivery – Partially breastfeeding till hospital discharge on day 2 – Breast engorgement on day 3 –4, baby latched shallowly and traumatised nipples – Mother reduced direct breastfeeding, did not express manually, and gave more bottle feeds
What has happened? Poor latch Inadequate latch
Unsatisfied baby
Reduces milk supply
FIL accumulates (Feedback inhibitor of lactation)
Early engorgement
More difficult to latch, nipple soreness
What she could have done on day 3 - 4
To increase breast milk supply • Increase demand to meet supply – Increase frequency of breastfeeding, get help to get correct latching – Express breast milk if baby does not effectively drain milk (increase 2x/day to 6-8 x/day) • Domperidone 10 or 20 mg tds for 2 weeks – Dopamine antagonist to increase prolactin levels
• Supplemental feeds while awaiting more milk production and/or healing of nipple
Mastitis, sore nipples and maternal medications
Scenario A breastfeeding mother with a 3-month old infant presents with a tender breast mass. She has flu-like symptoms and a temperature of 39° C. What is your management?
Mastitis - Treatment • Relieve pain - analgesics, cold compress • Empty the breasts- continue breastfeeding or expression • Antibiotics against Staphlococcus aureus – Cloxacillin, cephalexin or augmentin for 10 days
• Antibiotics and “infected” milk safe for infant consumption
Scenario • Mother breastfeeding her 2 month old child has an acute URTI – sore throat, runny nose, moderate fever 38 Celcius – What medications would you give her? – How can you check if medications are safe? – Can she continue to breastfeed?
Two unwanted effects of inadequate knowledge about breastfeeding and medications 1. Breastfeeding may be advised to be stopped by the physician 2. Mother may be non-compliant to her medications for fear of effect on baby
Simple maternal acute illnesses
• Continue breastfeeding • Protective antibodies are produced in the breast milk • Avoid multi-drug regimes
Medications to relieve symptoms • Analgesics – Paracetamol – NSAIDs • Antihistamines • Pseudoephedrine – may cause decreased milk production – long term use not recommended
Antibiotics • Most are compatible with breastfeeding • Many antibiotics used in infants • Mild adverse effects – Changes to intestinal flora → Candida infections – Very rarely idiosyncratic allergic reaction
Drugs and Lactation Database (LactMed) A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed Data included – maternal and infant levels of drugs – possible effects on breastfed infants and on lactation – alternative drugs to consider
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Cetirizine CASRN: 83881-51-0 For other data, click on the Table of Contents Summary of Use during Lactation: Small occasional doses of cetirizine would not be expected to cause any adverse effects in breastfed infants. Larger doses or more prolonged use may cause drowsiness and other effects in the infant or decrease the milk supply, particularly in combination with a sympathomimetic or before lactation is well established. Single bedtime doses after the last feeding of the day may be adequate for many women and will minimize any effects of the drug. The nonsedating antihistamines are preferred alternatives.
Other resources
Breastfeeding booklet From NUH website http://www.nuh.com.sg/_og/index.htm
Publications Health Brochure Breastfeeding: Natural is best
Resources for mother’s support NUH Breastfeeding Helpline 97220376 Lactation consultant on duty • General queries on breastfeeding • For outpatient lactation consultation appointments
Breastfeeding Mothers’ Support Group (Singapore) Counseling Hotline: 63393558 Email:
[email protected] website: http://www.breastfeeding.org.sg
“Successful breastfeeding requires education, support and an environment that values and understands breastfeeding.” • Education – Benefits of Breastfeeding Antenatal period – Management of breastfeeding – How to manage breastfeeding difficulties
• Support and Environment
Maternity Hospital
– A Baby-Friendly Maternity Unit Contact throughout infancy – Continued support from the family, health care professionals, and society
Health Professionals as
breastfeeding advocates • Promote, support and protect exclusive breastfeeding, as cultural norm • Develop knowledge about the benefits and clinical management of breastfeeding • A decision to choose not to breastfeed should occur only after the family has been fully informed of the risks of not breastfeeding
The Baby-Friendly Maternity Unit
